Tips For Successfully Negotiating With Managed Care Plans

Yes—You Can Negotiate!

By Bill Rossi
Published in The McGill Advisory, October 2014

Most doctors believe that when an insurance company provides them with a managed care (PPO) fee schedule, there’s no negotiating. That’s not the case, says practice management consultant Bill Rossi*, based in Minnesota, a managed care stronghold. While insurance companies undoubtedly hold the upper hand, negotiations are not only possible, but when successful, can lead to thousands of dollars in increased profits!

Rossi provides several reasons that insurance companies will negotiate. First, they want to keep patients where patients are happy. Also, they need to maintain the provider network to keep their employer-customers happy, and paying their premiums. Furthermore, many insurance companies reward their network managers for maintaining or building their network of participating doctors, and penalize them for related losses.

That being said, market conditions often dictate if, and how much, insurance companies are willing to bend, says Rossi. If managed care penetration in the area is relatively weak, insurance companies are more likely to negotiate because they need your practice to build their network. Furthermore, the fewer doctors that are a heady in the network, the more bargaining power you have. Also, the more patients you have in a given plan, the more negotiating power you wield since the loss of your practice would blow a bigger hole in their provider network.

The few doctors who do negotiate are often unnsuccessful because of their lack of preparation, knowledge, and skill, says Rossi. Too often, doctors negotiate fee increases on a handful of procedures, only to later determine that those were low-volume procedures that will only minimally increase practice profits. While they’ve won the battle, they’ve lost the war!

Doctors need to understand that insurance companies are not bound by antitrust rules and so they share the actual fees charged by you and all your competitors with each other. As a result, they have complete knowledge of the practice fee landscape, while doctors don’t. Furthermore, they often pay two doctors in the same town, doing the exact same procedure, different fees (varying as much as 40%). Often when insurance companies are seeking to expand their network, they offer a fee schedule that is well below what they may be paying other doctors already in their network, to see if the new doctor will “bite.”

In order to negotiate successfully, doctors should prepare well and pick their battles intelligently, says Rossi. He recommends establishing a fee grid detailing the fee reimbursements provided by each PPO plan for the top 20 procedures (by dollar volume) performed by the practice. Furthermore, doctors should also compute the discount off the practice’s full fee for each of these procedures. Once completed, the doctor should look for mistakes and inconsistencies between the plans, and use this information in the negotiating process.

Armed with this information, doctors are now ready to play “PPO poker,” says Rossi. He recommends calling the PPO network manager and negotiating directly. Avoid being confrontational or combative in the fee negotiation process, but rather try to be civil and informative instead.

If the fee the doctor is receiving is 40% of UCR from one PPO, but 65% of UCR for the same procedure from another plan, ask the underpaying plan if it is paying another doctor more for the same procedure. If so, tell them that they shouldn’t discriminate and should pay each doctor the same fee for the same procedure. Also, ask them if they would be willing to match the higher fee paid by the competing plan to keep you in the network.

It’s important for doctors to threaten to leave the network if reasonable fee requests are not met. Otherwise, the plan has no reason to negotiate with the doctor and will refuse to budge. While Rossi concedes that fee negotiations are successful less than half the time, when they are he has been able to increase reimbursements by up to 30% for some clients.

Also, look for added profit dollars from plan “glitches.” In some cases, Rossi has seen some procedure codes discounted more heavily than others due to insurance company errors. In other cases, the insurance company is simply not paying the correct (higher) fee that they agreed to pay under the contract. Rossi has also found errors when the insurance companies reset fees based upon an old, outdated fee schedule, resulting in the doctor’s reimbursements going down, rather than up, as agreed.

Going Out of Network

If your practice is already at full capacity, dropping a PPO plan is relatively easy and certainly cost-effective. If not at full capacity, doctors need advance preparation and a concrete plan of attack. Without one, Rossi says you can do serious damage to your practice!

First, doctors need to determine how much of their production and fee adjustments (write-offs) come from each plan and determine the related write-off percentage. Doctors also need to investigate and compare the in-network fees versus the out-of-network fees available if plan participation is dropped.

With all other factors being equal, Rossi recommends “peeling off’ the smallest PPO plan first, since it will be easiest to replace the lost volume. Before dropping a PPO plan, however, doctors need a three-step plan of attack. First, they need to develop strategies to minimize loss of patients from dropping the plan. Next, they need strategies to slow down that patient loss. Finally, they need to develop strategies to counteract, or offset, the loss of patients.

Doctors’ biggest fear in playing PPO poker is the effect that patient loss can have on their practice, says Rossi. While doctors will certainly lose patients when they drop a plan, the loss is usually not nearly as severe as feared. Many patients are loyal, and will stay with the practice if the situation is handled correctly, says Rossi. And doctors should be emboldened to act with the knowledge that if they leave the network, they can very likely come back, making this a very low risk decision.

Proper communication about the change in plan participation is critical. In most cases, doctors are best served by NOT sending letters to patients announcing that they are leaving the network. Rossi says that such letters often sound self-serving, and can confuse and irritate patients. Rather, he recommends developing the message (or script) and delivering it “face-to-face” to the patient while they are in the office. Over time, the doctor can refine the message based on patient responses to help minimize attrition. This approach also slows down the patient loss, providing more time for the doctor to implement marketing efforts to rebuild practice volume.

Rossi has had great success in negotiating increased fees from managed care plans when the conditions are right. Furthermore, he has performed many managed care “exorcisms” through dropping plan participation and converting practices from PPOs. He says these strategies can add more bottom line profits for mature practices than virtually any other.

In one recent situation, Rossi assisted a practice producing close to $70,000 a month, but who was so heavily involved in managed care participation that it was collecting only 63% of production. He performed exorcisms on several PPO plans and implemented new marketing strategies to boost new patient flow. While the level of practice production remained stable, the collection rate increased to 82%, up 19 percentage points. Thus, the doctor was able to increase collections and related profit also need to investigate and compare the in network fees by over $150,000 annually – not by working harder, by working smarter! That experience makes playing PPO poker not only fun, but also extremely rewarding!

If you have questions about whether your dental practice would benefit from going out of network with insurance, call Bill at (952) 921-3360 for a complimentary 20-minute consultation.